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Management of the Patient Presenting with Wide Complex Tachycardia Samir Saba, MD Director, Cardiac Electrophysiology.

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Presentation on theme: "Management of the Patient Presenting with Wide Complex Tachycardia Samir Saba, MD Director, Cardiac Electrophysiology."— Presentation transcript:

1 Management of the Patient Presenting with Wide Complex Tachycardia Samir Saba, MD Director, Cardiac Electrophysiology

2 Definition Heart rate > 100 b/min QRS > 120 ms

3 Differential Diagnosis Supraventricular tachycardia with aberrancy Pre-excited tachycardia Motion artifact Paced rhythm Ventricular tachycardia –Idiopathic –Non-idiopathic

4 Importance of diagnosing VT 1.Sensitivity versus Specificity 2.In all patients with WCT, VT is the diagnosis in 80% of cases

5 SVT with aberrancy Typical RBBB Typical LBBB

6 Typical bundle morphology LBBB RBBB



9 Pre-excited Tachycardia Manifest versus concealed AP

10 WPW


12 Antidromic AVRT

13 Atrial Flutter with Preexcitation

14 AF with Preexcitation

15 Motion artifact Failure to recognize artifact is common: –94% of internists –58% of cardiologists –38% of EP

16 Motion Artifact Recognize artifact by: Marching the high frequency signal across the WCT Looking at other available leads

17 Paced ECG

18 Paced Not Paced

19 Ventricular Tachycardia Idiopathic –RVOT VT –LVOT VT –Lt fascicular VT Non-idiopathic –ICM –NICM –HCM –Channelopathy (LQTS, Brugada, etc…)



22 Left fascicular VT

23 Other Classifications for VT Morphology: –Monomorphic –Polymorphic –Bidirectional Mechanisms: –Reentry –Automaticity –Triggered activity Drug susceptibility: –Verapamil sensitive –Adenosine sensitive

24 Repetitive VT


26 Non-idiopathic VT

27 Ventricular Tachycardia

28 Bidirectional VT

29 Mechanisms of VT

30 Approach to Management History Physical Exam ECG EP Study

31 History Age (if >35 yrs, VT>85%) Symptoms (palpitations, syncope, LH, diaphoresis, angina, seizures, CA…) Circumstances: N/V/D (electrolytes) PMH: Cardiac disease, MI, CHF, ICD, RF Family history: SCD, arrhythmias Medications: QT prolongation, digoxin, diuretics, etc… Habits: Drugs

32 Physical Examination Hemodynamic Stability Signs of acute CHF Sternal wound PVD Stroke PM/ICD Evidence of AV dissociation (cannon A waves, marked fluctuations in BP, variable S1 intensity) Maneuvers: CSM, pharmacologic interventions (lidocaine, adenosine, BB, verapamil)

33 Other tests Laboratory tests: K, Mg, plasma concentrations of drugs (dig, procan, etc…) CXR: cardiomegaly Echo: structural abnormalities

34 ECG During WCT: AV dissociation Fusion beats Capture beats Morphology –Width of QRS –Morphology of the bundles –Electrical axis –Precordial concordance In NSR: Ischemia Acute MI Old MI Long QT Brugada pattern LVH Epsilon waves

35 AV dissociation

36 Fusion beat

37 ECG


39 Therapy Acute Management: –For the Unstable patient: Emergent synchronized cardioversion If QRS and T cannot be distinguished then defibrillation Cautious use of sedatives and analgesics –For the Stable patient: Class I or III AAD Treatment of associated conditions (ischemia, electrolytes,…) Elective cardioversion Interrogation of ICD or PM if present

40 Therapy Chronic Management: AAD: – class IC or III, if structurally normal hearts – class III, if structurally abnormal hearts (with ICD) EPS+/-RFA –Stand alone therapy in idiopathic VT –Adjunctive therapy (+/-AAD) in ischemic VT ICD –For primary and secondary prevention of SCD

41 Indication for EPS

42 EP Study Induce the arrhythmia Activation or Pace mapping Ablation

43 Activation Map for VT

44 RVOT VT: pace map

45 Special Case: NSVT EF35%, then ICD EF>40%, no ICD 35%

46 Summary DDX of WCT includes VT, SVT with aberrancy, preexcited tachycardia, artifact, and paced rhythm. VT accounts for 80% Diagnosis hinges of good history, PE, ECG Acute management depends on stability of patient. In the unstable patient, immediate cardioversion or defibrillation is recommended Long term management armamentarium includes: AAD, Ablation, ICD

47 Holter Monitor in a Mouse

48 EPS in a Mouse

49 Question?…

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